varicose veins

1. Dr Shanavas C
DNB Trainee In General Surgery

2. They are dilated, tortuous, elongated veins in the leg.
There is reversal of blood flow through its faulty valves.
It is permanently elongated, dilated vein/veins with
tortuous path causing pathological circulation.

3. Risk factors being heredity; female sex; occupation that
demands prolongedstanding; immobility; raised intra-
abdominal pressure like in sports, tight clothing,
pregnancy, raised progesterone level and altered
estrogen-progesterone ratio, chronic constipation,
high
heels.
Prevalence of varicose veins is 35%; severe varicoseveins
is 10%;
chronic venous insuffi ciency (CVI) is 8%;
Ulcer is 2%.

4. Introduction
The venous drainage system of the lower extremity
consists of three sets of veins:
Deep veins,
Superficial veins
Perforating veins.
 All veins contain delicate one-way valves that
normally open to allow blood to flow toward the heart
and prevent blood from flowing in a retrograde
fashion after the valves close .

5. Veins of lower limb
1: Superficial veins:
Long saphenous vein
Short saphenous vein
2: Deep veins :
Anterior & Posterior Tibial veins
Peroneal vein
Popliteal vein
Femoral vein
3: Perforator veins

6. Long saphenous vein (LSV)
Largest and longest
superficial vein of the limb.
Begins on the dorsum of foot
from medial end of dorsal
venous arch.
Run 1 to 1.5 inch anterior to
the medial malleolus ,along
the medial side of the leg ,
and behind knee .

7. At the ankle the
position of the LSV is
constant , lying in the
groove b/w the
anterior border of the
medial malleolus and
tendon of tibialis
anterior.

8. In the thigh it inclines
forwards to reach the
saphenous opening where it
pierces the cribriform fascia
and opens into the femoral vein
3-4 cm below and lateral to the
pubic tubercle.

9. The long saphenous vein and deep fascia
In the lower 2/3 of leg and in
upper 2/3 of the thigh vein lie
on deep fascia .
 Where the vein crosses the
knee joint it become more
superficial and often
subcuticular .

10. The structures accompanying the LSV
In the leg saphenous nerve lies in close relation
with the LSV.
The nerve is very closely applied to the vein in lower
2/3 of leg and often injured in exploring or
stripping the saphenous vein .
In the thigh medial femoral cutaneous nerve run in
close relation with vein .

11. Throughout its length the LSV is accompanied by
lymphatic trunks draining the dorsum of foot and
anterior and medial aspects of the legs and thigh .
This lymphatic drain in superficial inguinal lymph
nodes.

12. Tributaries of LSV and communication
Just below knee LSV receive posterior arch vein
(Leonardo's vein) which collect the blood from post-
medial aspect of calf .
Anterior veins of leg(stocking vein) ascend across
the shin and join either LSV or posterior arch vein .
There is a free anastomosis b/w tributaries of short
saphenous vein and venous arch connecting medial
ankle perforating vein and this medial ankle
perforating veins are connected with LSV in lower
third of leg .

13. In the thigh before entering in the saphenous opening it
recieves
1. Anterolateral vein
2. Posteromedial vein of thigh
3. Superficial external pudendal vein
4. Superficial epigastric vein
5. Superficial circumflex iliac vein
6. Deep External Pudendal Vein
 In the lower third of thigh long saphenous vein connect with
femoral vein in hunter’s canal by long perforating vein
( hunterian perforator)

15. Short saphenous vein(SSV)
It begins by the fusion of
number of small veins
below and behind the
lateral malleolus . Here
vein runs with the large
sural nerve up to lower
third of leg.
 SSV is runs upward up to
the middle of the popliteal
space, where it passes
deep to fascia to enter into
popliteal vein .

16. In the lower third of the calf it lies on the deep fascia
and cover by skin and superficial fascia .
In the middle third of leg it enters in the intrafascia
compartment in the aponeurotic investment of the
gastrocnemius muscle .

17. Upper third of leg it penetrates the deep fascia and
enter popliteal space and lie b/w head of two
gastrocnemius muscle which lies 1.25cm below the
transvers skin crease behind knee .
Here SSV join popliteal vein .

18. Structures accompanying the SSV
Sural nerve in lower third of leg
Lymphatic trunk which drains
lateral aspect of foot and drain in
the popliteal lymph nodes.

19. Where the vein passes through fascia Posterior
cuteneous nerve emerges out from deep to superficial.
In the upper part of vein it communicates with LSV
via the posteromedial vein of Leg.
SSV may run above the popliteal space and end in
deep veins in lower thigh or may end in LSV in upper
thigh.

20. Deep veins
This veins lie in deep fascial plane and are supported
by powerful muscles of leg.
These are
1: Anterior and posterior Tibial veins
2: Peroneal vein
3: Popliteal vein
4: Femoral vein
These veins accompany with Arteries.

22. Perforating veins
These are communicating veins b/w superficial and
deep veins .
Two type:
1 Indirect veins
2 Direct veins

23. 1. Indirect perforating
veins:
 These consist of small
superficial veins which
penetrate the deep fascia
to connect with vessel in
muscle and in turn end in
Deep vein.

24. Direct perforating
veins :
These directly connect
superficial veins with
deep veins

25. Direct perforator
In thigh : Adductor canal
perforator connects long
saphenous with femoral vein in
lower part of adductor canal.
(hunterian’s perforator)
In the lower thigh on medial
aspect Long SV connect
femoral vein via DODD’s
Perforator
Below knee :
Perforator connects long SV or
post-Arch vein with posterior
tibial vein knows as BOYD’S
Perforator.
May/Kuster

26. In leg :
1.Lateral perforator is presented at the junction of
mid & lower third of leg .It connect SSV
with peroneal vein.
2. Medially there are three perforator which connect
posterior arch vein with posterior tibial vein , know as
COCKETT’S Perforator

27. Upper medial
perforator lies at the
junction of middle and
lower third of leg.
Middle medial
perforator lies 4Inch
above the medial
malleolus .
Lower medial perforator
lies posterio-inferior to the
medial malleolus .

28. Classification I
♦ Long/great saphenous vein varicosity.
♦ Short/small saphenous vein varicosity.
♦ Varicose veins due to perforator incompetence.

29. Classification II
♦ Thread veins (or dermal fl
ares/telangiectasis/spider veins/
Hypen veins are 0.5-1 mm in size): Are small varices
in the
skin usually around ankle which look like dilated, red
or
purple network of veins (Venulectasia). Spider
naevi/venous
fl ares are common in females.
♦ Reticular varices (1-4 mm in size): Are slightly

30. CEAP classifi cation
C— Clinical signs (grade 0-6); (A) for asymptomatic
or (S) for
symptomatic presentation
E— Etiological classification: Congenital (Ec),
Primary (Ep),
Secondary (Es), No venous etiology (En)
A— Anatomic distribution: Superfi cial (As), Deep
(Ad) or Perfo-
rator (Ap), No venous location identifi ed (An)
P— Pathophysiologic dysfunction: Refl ux (Pr),

31. Grading of clinical signs (C)
0—No visible or palpable signs of venous diseases
1—Telangiectases, reticular veins or malleolar fl are
2—Varicose veins
3—Oedema without skin changes
4—Skin changes due to venous diseases like
pigmentation,
eczema or lipodermatosclerosis 4a—pigmentation; 4b
—lipo-
dermatosis, atrophia blanche

32. As—superfi cial system:
1–Telangiectases, reticular veins
2– Great saphenous vein above the knee—ostial and
preter-
minal
3–Great saphenous vein below the knee
4–Small saphnous vein
5–Nonsaphenous—43%
Ad—deep system:
From 6 to 15

33. Pathogenesis
Fibrin cuff theory
White cell trapping theory

34. CVI
Chronic venous insuffi ciency (CVI) is a syndrome
resulting
from continuous chronic venous
hypertension/ambulatory
venous hypertension [AVP] (> 80 mmHg venous
pressure
at ankle) in the erect posture either on standing or
exercise
(in normal people venous pressure in superfi cial
system falls

35. CVI patients may
be having superficial vein incompetence (30%) with
or
without perforator incompetence or deep vein
incompetence
(30%) or having previous DVT with complete
obliteration
or partial recanalisation with incompetence called as
post-
thrombotic syndrome (30%)

36. Surgical modalities for
Varicose vein
o Ligation & Stripping of vein
o Ligation of Incompetent Perforators
1.Open subfascial ligation of perforators
2.Subfascial Endoscopic ligation of perforators
3,Extra fascial ligation of perforators
o Sclerotherapy
o Endovenous Laser Ablation
o Radiofrequency ablation

37. Etiology of varicose veins
Primary varicosities due to:
Congenital incompetence or absence of valves.
Weakness or wasting of muscles—defective connective
tissue and smooth muscle in the venous
wall.Stretching of deep fascia.
Inheritance (family history) with FOXC2 gene.
Klippel-Trenaunay syndrome, avalvulia, Parkes-
Webersyndrome. Here varices are of atypical
distribution.

38. Secondary varicosities:
Recurrent thrombophlebitis.
Occupational—standing for long hours (traffi c
police,
guards, sportsman).
Obstruction to venous return like abdominal tumour,
retroperitoneal fi brosis, lymphadeno pathy, ascites.
Pregnancy (due to progesterone hormone), obesity,
chronic constipation.
AV malformations—congenital or acquired.

39. Sites where varicosities can occur
Lower limb
Pampiniform plexus of veins
Vulva, perineum
Sites of portosystemic anastomosis

40. Clinical features
Visible dilated veins in the leg with pain, distress,
nocturnal
cramps, feeling of heaviness, pruritus.
♦ Pedal oedema, pigmentation, dermatitis,
ulceration, tender-
ness, restricted ankle joint movement.
♦ Bleeding, thickening of tibia occurs due to perio
stitis.
♦ Positive cough impulse at the saphenofemoral
junction.
♦ Saphena varix—a large varicosity in the groin,

41. Venous disability scoring system
Score 0 Asymptomatic
Score 1 Symptomatic but able to carry out
activities without any therapy
Score 2 Symptomatic—can do activities only
with compression/limb elevation
Score 3 Symptomatic—unable to do daily activities
even with
compression or limb elevation

42. Complications of Varicose Veins
 Haemorrhage:
Pigmentation, eczema and dermatitis
Venous ulcer.
 Marjolin`s ulcer
Lipodermatosclerosis.
 Deep venous thrombosis
 Calcifi cation of the wall of varicose veins or of
sclerosed soft tissue
 Recurrent thrombophlebitis.

43. Investigations-
Venous doppler
Duplex scanning
Venography
Plethysmography:
Photoplethysmography:
Air plethysmography

44. Ambulatory venous pressure (AVP):
Arm-foot venous pressure:
U/S abdomen, peripheral smear, platelet count, other
relevant investigations are done depending on the
cause of
the varicose vein
If venous ulcer is present, then the discharge is
collected for culture and sensitivity, biopsy from ulcer
edge is taken to rule out Marjolin’s ulcer.

45. Treatment
Conservative treatment:
Elastic crepe bandage application from below
upwards
or use of pressure stockings to the limb—pressure
gradiant of 30-40 mmHg is provided.

46. Drugs used for varicose veins:
Calcium dobesilate—500 mg BD. Calcium dobesilate
improves lymph fl ow; improves macrophage
mediated
proteolysis; and reduces oedema.
Diosmin—450 mg BD.
Diosmin 450 mg + Hesperidin 50 mg (DAFLON 500
mg). Mainly used in relieving night cramps but not to
improve healing of ulcers.
Toxerutin 500 mg BD, TID. Antierythrocyte
aggregation

47. Surgical modalities for
Varicose vein
o Ligation & Stripping of vein
o Ligation of Incompetent Perforators
1.Open subfascial ligation of perforators
2.Subfascial Endoscopic ligation of perforators
3,Extra fascial ligation of perforators
o Sclerotherapy
o Endovenous Laser Ablation
o Radiofrequency ablation

48. Surgery
Ligation and stripping of varicose vein :
Indication :
LSV /SSV incompetency .
Perforating vein incompetency.

49. Contraindications
DVT
Pregnancy
Thrombophlebitis
Peripheral vascular disease

50. Pre-op marking of varicose vein
As the varicose vein
disappear when pt lies
down on operating
table so its essential to
mark the course of the
major superficial
tortuous vein to be
removed.

51. Steps of surgery for LSV
After anesthesia
proper position is
given.
The whole table is
tilted head down to an
angle of about 10
degree. (trendlenberg
position)

52. Incisions :
1. Hockey stick incision
2. Oblique incision
Incision is kept at groin
at Saphenous opening 3-
4 cm below and lateral
to pubic tubercle.

54. After division of deep
layer of fascia ,
saphenofemoral
junction is exposed.

55. Then flush
saphenofemoral
ligation (&
tranfixation)
done with
ligation of all
tributaries of
long SV .

56. Then stripper is passed
down the saphenous vein
and directed downward by
finger .
.

57. Stripper delivered
through small incision
over ankle on medial
aspect

60. Vein is tied with stripper
and then stripper is slowly
and steadily pulled out
through lower wound.
The ‘vein bolus’ is
withdrawn slowly from the
lower wound.

61. The residual veins are then ‘wormed out ‘ using
multiple stab avulsions using vein hooks ,from
the preoperative marked sites.
Post operatively limb elevation and compression
stockings are given .

62. STEPS OF SURGERY FOR SSV
After anesthesia proper position is given.
The patient must be face down and the knee is flexed
a little, by placing sandbag under the ankle .
Some prefer lateral leg position.
The foot of the table is tilted up a little, so that legs
are above the heart.

64. Incision is kept atleast 5 cm long, transversely across
the popliteal fossa, in one of the transverse line of
skin about the level with knee joint.
The incision is deepened until the deep fascia and
short saphenous vein lies deep to this.
The fascia is divided transversely in the line of
incision.

65. The short saphenous vein is then seen or sought for
betweeen the two heads of gastrocnemius.
As soon as the SSV is identified, it is lifted up in a pair
of artery forceps and the knee is flexed still further.
Then flush saphenopopliteal ligation (& transfixation)
done with ligation of all the side branches of SSV,
right upto its junction with the popliteal vein.

66. Then stripper is passed down distally, directed by
finger.
And delivered to point below external malleous
through a small transverse incision.

67. INTRA- OPERATIVE
COMPLICATIONS OF THE
SURGERY
BLEEDING FROM A TORN SAPHENA VARIX
 INJURY TO COMMON FEMORAL VEIN
 INJURY TOCOMMON FEMORAL ARTERY
INJURY TO SAPHANEOUS NERVE
INJURY TO SURAL NERVE

68. IMMEDIATE POST-OP CARE
Three factors to be kept in mind in the first week :
1 Maintenance of firm elastic pressure over whole
limb.
2 Regular movement and exercise of the legs
3 Elevation of the foot of the bed 6 to 9 inches so that
the legs are just above the heart level when the
patient is in bed.

69. POSITION :
The foot of the bed is raised 6 to 9 inches
Patient is not allowed more than 2 pillows.

70. BANDAGING :
The original firm crepe bandage put on at the
operation should remain untouched for seven days

71. GETTING UP :
Started 24 hrs after the operation.
When the foot is placed on the ground for the first
time, extra firm webbing elastic bandage are placed
over knee and ankle.
At 7 days the stitches are removed.
A firm webbing elastic bandage from ankle to knee is
worn through-out the day for a whole fortnight.

72. Post operative complications
Haematoma and buising
- normally bruise absorbed within 3-4 wks
- small haematos get reabsorbed large haematomas
more than 4 cm evacuated with sterile precaution
under LA with sterile precautions
Lymphatoma
-Generally occurs on 5-6 post op day
-Get absorbed within 1-2 wks
-Should not be interveined as may lead to lymphatic
fistula formation

73. Wound sepsis
Post operative saphenous neuritis
Lymphoedema of leg
Induration of stripper tract
DVT and embolism

74. Extra fascial ligation of
perforators(Cocketts
procedure)
Not commonly employed
Aim is to clear all the extrafascial veins
More traumatic due to adherence of subcutaneous fat
and connective tissue to the fascia

75. Subfascial Endoscopic
Perforator Surgery
People who suffer
with leg ulcers due
to incompetent
venous perforators

76. Indication :
Incompetent perforating veins in calf with no
superficial venous reflux or no evidence of DVT on
Doppler .
Patient with LSV / SSV varicosity with ulcer

77. Procedure
Using spinal or general anesthesia a ¾ inch
incision is made on the inside of the calf.
 An instrument is inserted deep to the fascia of
the leg and a large balloon is inflated with water
to create a working space.
The balloon is then emptied and the space is
insufflated with air.
The camera is inserted and the perforator veins
can be seen in the space passing from superficial
to deep layers.

78. Another small incision is made in the calf for passage
of another instrument.
 The perforator veins are carefully dissected,
 Clips are applied and the veins are divided if
necessary.
 All trocars are then removed and the wounds are
closed.
 The patient is generally sent home the same day of
surgery with elastic stocking.

79. Obliteration of venous lumen - Methods
1. Foam Sclerotherapy
2. Laser
3. Radiofrequency Ablation

80. Foam Sclerotherapy
Principal :
By injecting
sclerosant into a
varicose vein, destroy
its endothelium in
that area , and thus
induce an aseptic
thrombosis which
organises and closes
the vein.

81. Indication :
Residual vein after
surgery
Large venous
telangiectases.
Isolated small dilated
veins
Contraindication :
Pregnancy
Pelvic tumor
Sup thromboplebitis at
the time of procedure
DVT
Previous h/o reaction to
sclerosant

82. SOLUTIONS :
SODIUM TETRADECYL SULPHATE
SOD.MORRHUATE
HYPERTONIC SALINE SOL.
POLYDOCANOL,SOTRADECOL
ETHANOLAMINE OLEATE
GLUCOSE COMBINATIONS

83. `
PROCEDURE :
Depending upon the size of
vein to be occluded, sclerosant
is taken in 20 ml syringe and
connected to another syringe
with 4 times the amount of air.
By repeated to and fro motion
of the solution and air into
syringes , dense white foam is
prepared .

84. After giving position under USG
guidance needle is inserted into
the vein .
And sclerosant is injected into
the vein .
Not more than 20 ml foam
should be injected at one sitting ,
Multiple sitting may be required
for successful obliteration of
vein
The foam being dense , does not
“run-away” up the vein, it require
massaging the skin over varicose
vein.

85. Immediately after foam
injection compression
stocking is applied and
patient is mobilized .
Patient can go home on
the same day of
procedure.
After 48 hr of procedure
USG is done to R/o
DVT

86. Advantage
Cheap
Easy to learn
Truly an OPD procedure
Can be repeated many
times
No anesthesia required
Disadvantage
Not suitable for SFJ/SPJ
obliteration
Thrombophebitis
Pigmentation over skin
More than 3 wks
compression is required

88. Endovenous Laser Treatment (EVLT)
Principal :
EVLT initiate a
nonthrombotic occlusion
by direct thermal injury to
vein wall, causing
endothelial denudation ,
collagen contraction and
later fibrosis.

89. Indication :
Long saphenous vein
varicosity
Short saphenous vein
varicosity
Contraindication :
Superficial vein
thrombophlebitis
DVT

90. Procedure
EVLT is done under local
anesthesia under USG
guidance.
Varicose vein is marked
preoperatively
Supine position is given
Vein is canulated with 0.035” J
guide-wire via 19G needle.
The Laser fiber is then
introduce over it under USG
guidance upto 2-3 cm distal to
SF junction.

91. Fiber is withdrawn at the rate
1-3mm / sec under USG
guidance .
This laser fiber causes thermal
damage to the venous
endothelium(1000 c) and
occlusion of lumen by fibrosis.
Immediately after procedure
compression stockings are
given.
Patient can be discharge on
same day with good analgesics
and with compression
stockings.

92. ADVANTAGE
Minimal invasive
procedure
No post op scar
Done with local
anesthesia
Minimal post-op pain
Recurrence rate ( at 2
year f/u only 3%
DISADVANTAGE
Costly procedure
High technical skills req
Color Doppler and
Radiologist is req
Skin burns
Thrombophebitis
Paresthesia

93. Radiofrequency Ablation
This technique based on same
principal of EVLT
Here instead of laser fiber ,
special heater probe is inserted
which work at 85 -120 c
Probe directly comes in contact
with vein wall & causes tissue
damage .
A 45 cm of vein segment takes
only 3-5 min
Patient can directly go to home
after procedure.

94. TRIVEX
Alternative to avulsion phlebectomy for superficial
vein excision.
In this technique with the help of transcutaneous
light, veins are seen and extracted with the help of
suction dissector.

95. Thank You